An unnamed patient died after a gruesome bout with bedsores. But in a report quietly completed this week, investigators concluded that the VA staff had acted properly.

"Although the patient developed pressure ulcers ... we did not substantiate that the pressure ulcers were the result of nursing neglect or physical abuse," the investigators with the Department of Veterans Affairs Office of Inspector General said.

The investigators found that the VA staff had correctly assessed the patient and initiated the appropriate "interventions." The patient himself had refused recommended medical treatment in some cases, investigators noted.

"It confirmed our initial review in this case," Dr. Wessel Meyer, the chief of staff of the VA Central California Health Care System, said in a telephone interview Thursday.

At the same time, Fresno-area officials said the incident had prompted them to boost their "wound-care" team of nurses and medical professionals serving the VA's Fresno community living center.

"We're always looking for ways to improve care at our facilities," said Danielle Shapazian, the associate chief of staff in charge of quality management.

The 14-page inspector general's report ends an investigation that began last January after a complaint to the agency's hotline. Such complaints are relatively common. Last fiscal year, the VA hotline reported receiving 29,337 "contacts" and officials opened 885 formal investigations as a result.

The complaints often come up short. In the past year, for instance, investigators examined but ultimately dismissed whistleblower complaints that VA doctors in Boise, Idaho, were violating conflict-of-interest rules on patient referrals.

In other cases, though, complaints prompt troubling discoveries. Hotline complaints, for instance, led VA investigators to find that several veterans had been poorly cared for in Martinez, Calif., and at a Long Beach, Calif., radiation therapy facility.

The Fresno-based VA system serves about 26,000 veterans in six San Joaquin Valley and mountain counties. It includes clinics as well as the 60-bed community living center, which provides nursing and rehabilitation.

On Jan. 10, someone told investigators that a patient had developed bedsores, also called pressure ulcers, because of "neglect and abuse" at the clinic and in the community living center.

Bedsores are serious. They form when constant pressure on parts of the body shuts down the blood vessels that supply that area of the skin; hospital patients become prone to them if they aren't moved or rotated.

The patient was a man in his 70s, suffering from kidney disease, diabetes and high blood pressure, among other ailments. Admitted to the hospital last October, he needed a Foley catheter inserted in his penis to drain his bladder.

Over time, investigators reported, the periodically confused patient developed ulcers on the edge of his penis and on his tailbone. Medical staff took various precautions. After about a month, the patient went home.

In December, the patient returned to the hospital, where doctors found multiple bedsores. The patient's family declined to have a tube inserted for feeding. In mid-December, after being discharged again, he died. Several weeks later, the complaint was filed and the inquiries began.